Juha-Jaakko Sinikumpu

The increasing incidence of paediatric diaphyseal both-bone forearm fractures and their internal fixation during the last decade

BACKGROUNDnThe incidence of childrens forearm fractures is increasing worldwide. This is different from the declining trend observed in the overall injury rate, and the reason for the increase is not known. Diaphyseal forearm fractures comprise 3-6% of all paediatric fractures, and they offer a challenge to their treatment. The purpose of this study was to evaluate the incidence of diaphyseal both-bone forearm fractures in children during the last decade in Northern Finland. Another objective was to study the background factors, treatment, and re-displacement of these fractures.nnnMATERIALS AND METHODSnAll 168 children (<16 years) admitted to our paediatric trauma centre due to diaphyseal both-bone forearm fractures during 2000-2009 were included. The type of injury, background factors, radiographics, treatments and re-dislocations were reviewed. The age-related incidence rates were evaluated.nnnRESULTSnThe incidence of diaphyseal both-bone forearm fractures increased 4.4-fold (95% CI 2.0-10.8; P<0.001) between 2000 (8.2/100000) and 2009 (35.9/100000). The increase in the incidence was accelerating (P<0.001) and the overall increase was 338%. The incidence of surgical treatment for diaphyseal fractures increased 4.2-fold (95% CI 1.9-10.4, P=0.001), which is in relation to increasing number of fractures. However, internal fixation increased from 13.3% in 2000-2001 to 52.7% in 2008-2009 (P=0.015), as an alternative to conservative treatment. The re-displacement rate was high (29.9%) amongst the patients with conservative treatment compared to those who were invasively operated (1.4%) (P<0.001). The mean age of the patients increased by 2.4 years in the study period (P=0.019). Trampoline was the most important and still increasing reason for the fractures. At the beginning of the study, there were no trampoline-related fracture, but towards the end of the study 30-41% of the fractures were caused by a trampoline injury (P=0.004).nnnCONCLUSIONSnThere was an accelerating increase in the incidence of paediatric diaphyseal both-bone forearm fractures during the last decade. Trampoline was the most important and still increasing reason for these fractures. The mean age of the patients was increasing. Increasing proportion of diaphyseal both-bone forearm fractures was treated operatively. Re-displacement was unusual amongst operated cases.

Complications and radiographic outcome of children's both-bone diaphyseal forearm fractures after invasive and non-invasive treatment

BACKGROUNDnThe incidence of paediatric forearm fractures and their invasive operative treatment is increasing. Evidence supporting increased interest in internal fixation of forearm fractures has been controversial. We studied radiographic outcome and complications of both-bone diaphyseal middle-third forearm fractures according to the type of treatment. The purpose of the study was to determine if there is an advantage in invasive treatment over non-invasive treatment that supports the increasing trend towards invasive surgery.nnnMATERIALS AND METHODSnAll children and adolescents (<16 years) with both-bone diaphyseal middle-third forearm fractures in a geographic area with 86,000 children in 2000-2009 were included. There were 168 patients. The types of primary fractures and their malalignment and displacement rates were analysed. The fractures were classified as severe or mild according to radiographic findings. Radiographic fracture healing and alignment and the rate of complications were compared as regards invasive versus non-invasive surgery.nnnRESULTSnJust over a third of all patients suffered from some complication during follow-up. The overall complication rate was highest in the non-invasive treatment group (58%) and lowest in the intramedullary nailing group (24%) (P < 0.001). The difference was significant as regards both mild and severe fractures. Nearly a third of the fractures in the non-invasive treatment group were re-reduced during follow-up. Two third of them were finally fixed invasively. Re-reduction after invasive fixation was rare (1.4%, P = 0.001). Re-fracture was equally uncommon (7.1%) in both the invasive and non-invasive groups. Non-union was unusual (1.2%) and it was related to high-energy trauma or chronic disease. Nerve co-morbidity, scar problems, soft-tissue complications and compartmental syndrome were not problems in the study population despite the type of treatment.nnnCONCLUSIONSnWe found that the complication rate of diaphyseal forearm fractures was twice as common after non-invasive than after invasive treatment. The need of re-reduction after non-invasive treatment was remarkable. Nevertheless, bone healing was equally good despite the treatment. We conclude that intramedullary fixation of both-bone forearm fractures is a good mode of primary treatment of mild and severe middle-third diaphyseal both-bone forearm fractures.

The changing pattern of pediatric both-bone forearm shaft fractures among 86,000 children from 1997 to 2009

INTRODUCTIONnForearm fractures are common among children. Unlike most pediatric fractures, there is a risk of unsatisfactory results in forearm shaft fractures. The healing of a tubular bone is most unlikely in the diaphysis far away from the metaphyseal zones. The treatment of forearm shaft fractures is evolving. The purpose of the study was to analyze the pattern of forearm shaft fractures and their treatment in a population of children in recent years.nnnMATERIALS AND METHODSnAll the children (from 0 to 16 years) with a both-bone forearm shaft fracture (AO-segment 22-D) during the years 1997 to 2009 in a catchment area of about 86,000 children were included in this population-based study. There were 291 fractures in all. The age-related annual incidences, background factors, seasonal variation, injury types, treatment, reoperations, and short-term outcome were determined.nnnRESULTSnThe incidence of all forearm shaft fractures increased threefold in 1997 to 2009 (p < 0.001). Boys predominated (70%) over the girls (p < 0.001). The mean age of the patients was 8.7 years (SD, +/- 3.8) among both genders. The fractures were most common in August and most uncommon in December (p < 0.001). A fall in the playground was the most common type of injury (34%). Ninety-two percent of all patients (N = 269) were treated in the operating room and 44% (N = 119) were invasively stabilized. The incidence of invasive surgery held stable. However, elastic stable intramedullary nailing (ESIN) increased from 10% in 1998-2000 to 30% in 2007-2009 (p = 0.043). There were 77 reoperations (26%); reoperation rate was 5% (6/119) and 41% (N = 71/172) in the invasive and non-invasive treatment groups, respectively. Twenty-three percent of the patients referred did not have better than good short-term results. The excellent short-term outcome was increasing (p = 0.031).nnnCONCLUSIONSnWe found two mega-trends in pediatric forearm shaft fractures in the period from 1997 to 2009: First, the number of fractures was increasing significantly. Second, the forearm shaft fractures were increasingly treated by an invasive intramedullary method. We also found a significant seasonal variation, but the reason for it is not clear. The findings are based on valuable population-based data and the results are certain. Pediatric trauma centres should prepare themselves for on-going changes in forearm shaft fractures.

Nonoperatively treated forearm shaft fractures in children show good long-term recovery

Background and purpose — The incidence of forearm shaft fractures in children has increased and operative treatment has increased compared with nonoperative treatment in recent years. We analyzed the long-term results of nonoperative treatment. Patients and methods — We performed a population-based age- and sex-matched case-control study in Vaasa Central Hospital, concerning fractures treated in the period 1995–1999. There were 47 nonoperatively treated both-bone forearm shaft fractures, and the patients all participated in the study. 1 healthy control per case was randomly selected and evaluated for comparison. We analyzed clinical and radiographic outcomes of all fractures at a mean of 11 (9–14) years after the trauma. Results — The main outcome, pronosupination of the forearm, was not decreased in the long term. Grip strength was also equally as good as in the controls. Wrist mobility was similar in flexion (85°) and extension (83°) compared to the contralateral side. The patients were satisfied with the outcome, and pain-free. Radiographally, 4 cases had radio-carpal joint degeneration and 4 had a local bone deformity. Interpretation — The long-term outcome of nonoperatively treated both-bone forearm shaft fractures in children was excellent.

Atraumatic Compartment Syndrome of the Foot in a 15-year-old Female

Compartment syndrome is a surgical emergency that usually occurs as a sequel to high-energy trauma. We report an uncommon presentation of atraumatic compartment syndrome of the right foot involving the abductor hallucis muscle. A 15-year-old female presented with pain and mild swelling of the right foot after taking part in a school sports activity. Compartment syndrome was diagnosed, >2 months of conservative treatment failed to improve her symptoms, and surgical release and debridement were performed. Our clinical experience demonstrates that compartment syndrome of the foot may occur after mild sports activity in physically inactive children.

Population-based research on the relationship between summer weather and paediatric forearm shaft fractures

BACKGROUNDnPaediatric forearm shaft fractures show an increasing incidence. The predictive factors of these fractures are not fully understood. Summer weather is suggested to have an effect on the risk of childrens fractures. We studied the effect of rainfall, temperature and wind on paediatric forearm shaft fractures in summer.nnnMETHODSnAll 148 childrens forearm shaft fractures in the geographic catchment district during the summer months in 1997-2009 were included. There were 1989 days in the study period. Daily meteorological readings captured the maximum daytime temperature, precipitation and wind speed. The direct daily association between fractures (yes/no) and different weather conditions was analysed in this population-based study.nnnRESULTSnThe risk of forearm shaft fracture was 50% higher on dry days compared to rainy days (P=0.038). Temperature and wind speed had no statistically significant effect on fractures.nnnCONCLUSIONSnThe results give support for the presumption by the general public and professionals that summer weather affects childrens fractures. A 1.5-fold increase in the risk is especially significant as the forearm shaft fractures are challenging to manage and prone to complications. Paediatric trauma units should prepare themselves for these severe injuries on dry summer days.

Low incidence of flexion-type supracondylar humerus fractures but high rate of complications

Background and purpose — Supracondylar humerus fractures are the most common type of elbow fracture in children. A small proportion of them are flexion-type fractures. We analyzed their current incidence, injury history, clinical and radiographic findings, treatment, and outcomes. Patients and methods — We performed a population-based study, including all children <16 years of age. Radiographs were re-analyzed to include only flexion-type supracondylar fractures. Medical records were reviewed and outcomes were evaluated at a mean of 9 years after the injury. In addition, we performed a systematic literature review of all papers published on the topic since 1990 and compared the results with the findings of the current study. Results — During the study period, the rate of flexion-type fractures was 1.2% (7 out of 606 supracondylar humeral fractures). The mean annual incidence was 0.8 per 105. 4 fractures were multidirectionally unstable, according to the Gartland-Wilkins classification. All but 1 were operatively treated. Reduced range of motion, changed carrying angle, and ulnar nerve irritation were the most frequent short-term complications. Finally, in the long-term follow-up, mean carrying angle was 50% more in injured elbows (21°) than in uninjured elbows (14°). 4 patients of the 7 achieved a satisfactory long-term outcome according to Flynn’s criteria. Interpretation — Supracondylar humeral flexion-type fractures are rare. They are usually severe injuries, often resulting in short-term and long-term complications regardless of the original surgical fixation used.

Ulnar nerve morbidity as a long-term complication of pediatric supracondylar humeral fracture

BackgroundSupracondylar humeral fractures are common in children. We studied long-term ulnar nerve symptoms secondary to these fractures and analyzed the treatment for ulnar neuropathy.Materials and methodsThe cohort included 91 patients with a supracondylar humeral fracture in childhood, on average 12xa0years previously, in the geographic catchment area. All the cases were reexamined in regard to ulnar nerve morbidity. Cases with secondary ulnar neuropathy were treated nonoperatively and operatively.ResultsUlnar neuropathy was present in four cases (4.4xa0%). They all had suffered from a dislocated fracture, and they had been operated primarily. Another three patients had slight ulnar nerve symptoms. Hence, the total prevalence of secondary ulnar nerve morbidity was 7.7xa0%. A jumping nerve was seen in 9.9xa0%; 51.6xa0% had a diminished axial angle.ConclusionsWe report a defined pattern of long-term ulnar nerve morbidity after pediatric supracondylar humeral fracture. The prevalence of neuropathy is alarming in the young population (<25xa0years of age).

MRI-guided percutaneous retrograde drilling of osteochondritis dissecans of the talus: a feasibility study

ObjectivesThe purpose of this study was to evaluate the feasibility of MRI guidance for percutaneous retrograde drilling in the treatment of osteochondritis dissecans of the talus (OCDT).MethodsFour patients, one juvenile and three adults, with one OCDT lesion each and persisting ankle pain after conservative treatment, were treated with MRI-guided retrograde drilling. All lesions were stable and located in the middle or posterior medial third of the talar dome. Pain relief and the ability to return to normal activities were assessed during clinical follow-up. MRI and plain film radiographs were used for imaging follow-up.ResultsTechnical success was 100xa0% with no complications and with no damage to the overlying cartilage. All patients experienced some clinical benefit, although only one had complete resolution of pain and one had a relapse leading to surgical treatment. Changes in the pathological imaging findings were mostly very slight during the follow-up period.ConclusionsMRI guidance seems accurate, safe and technically feasible for retrograde drilling of OCDT. Larger series are needed to reliably assess its clinical value.Key Points• MRI serves as a useful guidance method for numerous mini-invasive applications.• Retrograde drilling is a cartilage-sparing alternative in the treatment of osteochondritis dissecans.• MRI guidance seems feasible for treatment of osteochondritis dissecans of the talus.

Severe osteogenesis imperfecta Type-III and its challenging treatment in newborn and preschool children. A systematic review.

Osteogenesis imperfecta (OI) is a group of genetic disorders, of which Type III is the most severe among survivors. The disease is characterised in particular by bone fragility, decreased bone mass and increased incidence of fractures. Other usual findings are muscle hypotonia, joint hypermobility and short stature. Fractures and weak bones may consequently cause limb and spinal deformity and chronic physical disability. Bisphosphonates have revolutionised the treatment of newborn children with severe OI type III. Surgery is still needed in most patients due to high frequency of the fractures. In this systematic review we describe the present state-of-art in treating the most severe type of OI in newborn and preschool children with their bone fractures.